Lecture 29 - Pleural Disease: Clinical

Question 1

Pleural effusions on X-ray can appear a couple different ways: A. There is loss/blunting of the ________ angle.

B. There is brightness overlaying the border of the __________, making it indiscernible (keep in mind this is NOT definitive for Pleural effusion –> it could also be consolidation or atelectasis).

C. _____ sign

Answer 1

A. Costophrenic angle

B. Hemidiaphragm

C. Menisucus sign

Question 2

When performing a thoracentesis to drain a pleural effusion, why is the needle inserted at the superior boarder of the rib?

Answer 2

There is a neurovascular bundle on the inferior border of the ribs that we want to avoid.

Question 3

It is important to determine if pleural effusion is Transudate or Exudate. It is considered Exudate if any one or more of the following is true:

Pleural fluid / serum protein ratio > ____

Pleural Fluid / Serum LDH rato > ____

Pleural Fluid LDH > _____ of the upper limit of normal Serum LDH.

Answer 3

Pleural Fluid / serum protein > 0.5

Pleural Fluid / serum LDH > 0.6

Peural Fluid LDH > 2/3 of the upper limit of normal Serum LDH

Question 4

If Pleural Effusion is determined to be Transudate, we consider which 4 causes?

Answer 4

1. Congestive Heart Failure (CHF)
2. Cirrosis of the liver
3. Nephrotic syndrome
4. Hypoalbuminemia

Question 5

Distinguishing among the different classes of Parapneumonic Effusions:

Uncomplicated

• Volume: _____
• Fluid color/quality: _____
• pH: ____
• Glucose: ____
• LDH: ____

Complicated

• Volume: _____
• Fluid color/quality: _____
• pH: ____
• Glucose: ____
• LDH: ____

Empyema

• Volume: _____
• Fluid color/quality: _____
• pH: ____
• Glucose: ____
• LDH: ____

Answer 5

Uncomplicated

• Volume: Usually Low
• Fluid color/quality: Serous/turbid
• pH: 7.3+
• Glucose: > 40
• LDH: < 1000

Complicated

• Volume: Variable
• Fluid color/quality: Turbid
• pH: 7.1 - 7.29
• Glucose: < 40
• LDH: Occasionally > 1000

Empyema

• Volume: Variable
• Fluid color/quality: Pus
• pH: Usually < 7.1
• Glucose: < 40
• LDH: Often > 1000

Question 6

How does the treatment differ between Uncomplicated Parapneumonic Effusion, Complicated Parapneumonic Effusion, and Empyem?

Answer 6

All are treated with Antibiotics, but Complicated and Empyema require placement of a drain.

Question 7

______ Pleural effusion is not always indicative of Lymphoma; it can arise from trauma or something that would cause damage to the Thoracic duct. It appears similar to Empyema, but it is will have high levels of _______, while Empyema will not.

Answer 7

Chylous pleural effusion

Triglycerides

Question 8

_______ is a proceedure that causes inflammation and resultant fibrosis of the pleural space (basically you get rid of the pleural space altogether). When and on whom is this performed?

Answer 8

Pleurodesis

It is performed on patients who have Pleural effusions due to malignancy and who have poor prognosis (short time to live). It prevents continuous hospital visits for drainage of effusions that keep occuring due to the malignancy.

Question 9

_____ Pneumothorax is so termed because it does not occur as a result of underlying disease (which is what happens with ______ Pneumothorax). Look for these patients to have a _____ and _____ body structure.

Answer 9

Primary

Secondary

Tall and Thin

Question 10

Keep in mind that Pleural Effusion secondary to _____ _____ will be Exudate.

Answer 10

Pulmonary Embolism